Seismic Compliance Frequently Asked Questions

For questions or comments related to the seismic frequently asked questions, please email the Seismic Compliance Unit (SCU).

General Questions#

1. Do I need to submit drawings with the Seismic Evaluation Report?#

The submittal requirements for the seismic evaluation can be found in 2022 California Administrative Code, Chapter 6, Section 1.3, Seismic Evaluation and all subsections which follow. These provisions stipulate that certain drawings and plans are an integral part of the Seismic Evaluation Report. The evaluator shall use drawings, diagrams, and details to accurately present the information necessary to communicate evaluated conditions and details of the subject existing building system.

The graphical information can be presented and incorporated in the evaluation report.  

PDF format is acceptable, oversized documents that are too large for email, CD or USB may be uploaded using our Secure File Transfer (SFT) website, click to request an SFT link.

2. Which Acute Care Hospitals are designated as rural and small hospitals in Seismic Zone 3?#

Rural & Small Hospitals in Seismic Zone 3#

Hospital Facility Name	Notes
Alta District Hospital	Peer Group 5
Barton Memorial Hospital
Biggs-Gridley Memorial Hospital
Bloss Memorial District Hospital
Central Valley General Hospital	Federal Designation
Chowchilla District Memorial Hospital
Colusa Community Hospital
Corcoran District Hospital
Del Puerto Hospital
Dos Palos Memorial Hospital
Eastern Plumas District Hospital
Glenn General Hospital
Hanford Community Hospital
Indian Valley Hospital
John C. Fremont Hospital
Kingsburg District Hospital	Peer Group 5
Lassen Community Hospital
Lindsay Hospital Medical Center
Mark Twain St. Joseph′s Hospital
Marshall Hospital
Mayers Memorial Hospital
Memorial Hospital, Exeter	Peer Group 7
Mercy Medical Center, Mt. Shasta
Modoc Medical Center
Needles-Desert Community Hospital
Oak Valley District Hospital	Peer Group 5
Palo Verde Hospital
Plumas District Hospital
Sanger Hospital	Peer Group 5
Selma District Hospital
Seneca District Hospital
Sierra Nevada Memorial Hospital	Federal Designation/  Peer Group 5
Sierra Valley Community Hospital
Sierra-Kings District Hospital	Peer Group 5
Siskiyou General Hospital
Sonora Community Hospital	Peer Group 5
St. Elizabeth Community Hospital
Surprise Valley Community Hospital
Sutter Amador Hospital
Tahoe Forest Hospital
Trinity Hospital
Tuolumne General Hospital

3. Can a different format be used for the “Compliance Plan Schedule” than the one specified in the regulations if we add a space for the governing codes and the year of construction?#

2022 California Administrative Code, Chapter 6, Section 1.4.4.4 specifies the items required for a complete “Compliance Plan Schedule” and Section 1.4.4.5 specifies the information required for the “Existing and Planned Buildings Matrix”. An augmented version of these documents is acceptable only if all the required items are included in the modified document.

4. We are doing a major SB 1953 retrofit on a hospital building. Will this trigger compliance with accessibility for disabled persons? Does the answer change if functional service areas are remodeled? Is there any range on cost to do accessibility changes?#

Where the total cost of a retrofit, or remodel, exceeds the current valuation threshold discussed below, and the Office determines that the cost of full compliance is an unreasonable hardship, compliance shall be provided to the greatest extent possible; but in no case shall be cost of compliance be less than 20 percent of the cost of the alterations, structural repairs or addition.  Where the total construction cost of a retrofit or remodel project does not exceed the most current valuation threshold and the cost of compliance with the accessibility requirements is disproportionate (i.e. exceeds 20% of the total project cost) without the required accessibility features, an “unreasonable hardship” may also exist. The Office will use the most current valuation threshold in determining if a retrofit or remodel project would create an “unreasonable hardship”. The  2021 valuation threshold is $172,418.00 and OSH-FD-800 application can be used when applicable. 

The latest enforceable accessibility requirements for persons with disabilities contained in CBC Section 11B-202.4, Part 2, Title 24 (referenced from California Existing Building Code Section 305A.1) apply to any project submitted to the Office for hospital building retrofit or remodel, pursuant to SB 1953 regulations. HCAI/OSHPD does not have the authority to enforce federal (ADA) accessibility requirements for disabled persons.  If functional service areas are remodeled, the remodeled area will also need to comply with any accessible elements and path-of-travel requirements associated with the specific area of remodel.  For additional information refer to Code Application Notice (CAN) 2-11B.

5. Can a conforming hospital building (SPC 3, 4, 4D or 5) be supplied with utilities emanating from a SPC 1 hospital building?#

A SPC 1 hospital building will cease operation as a general acute care hospital building at the end of the maximum extension granted to that building. Refer to California Existing Building Code Section 307A.1.1.1 for additions, alternations and remodels of conforming hospital buildings.

6. Which buildings fall under SB 1953, in cases where the building contains more than one licensed category of service?#

Though a hospital building may provide different categories of services, HCAI is not aware of any hospital buildings which are licensed under multiple licensure categories. 2022 California Administrative Code, Chapter 6, Section 1.2, Definitions, has the term “General Acute Care Hospital” which specifies the types of buildings included under the auspices of SB 1953. This definition states in part that Hospital owners have various options under SB 1953 provisions for the continued use of noncompliant buildings. As part of the compliance plan, hospital owners may choose to remove all acute care services from selected buildings subject to the approval of the Department of Health Services Licensing and Certification Division (L&C).

7. If a Static Nonlinear (Pushover) design approach is used, can the hospital utilize the same engineering specialist that assists with the analysis to provide the peer review functions? #

No, see 2022 California Building Code Section 1617A.1.41, Part 2, Title 24.

8. How do I add a hospital building to OSHPD’s building inventory, or certify an SPC 5/NPC 4 rating for a new building?#

To add a building to OSHPD’s hospital inventory, or to certify a new building as SPC 5/NPC 4, submit an application to the Seismic Compliance Unit (SCU) and include the following:

1. Complete the first 4 pages of HCAI-OSH-121 Application for New Project.
   • For Project Type, under Seismic Retrofit Program, select Application for Seismic Evaluation Report.
   • On page 2 for Record Detail write “Add a Building” in the Record/Project Name.

2. Submit an Evaluation of the building per 2022 California Administrative Code (CAC), Chapter 6. If the building is a new OSHPD approved construction a letter stating that the building is conforming per 2022 CAC, Article 2.0.1 (Item 2.1) and Article 11.01.2 (Item 2) will suffice.

2022 California Administrative Code (CAC), Chapter 6

2022 CAC, Article 2.0.1, Item 2.1
A conforming building as defined in Article 1, Section 1.2, may be placed into SPC 5 in accordance with Table 2.5.3 under the following circumstances:
a. The building was designed and constructed to the 1989 or later edition of Part 2, Title 24, and
b. If any portion of the structure, except for the penthouse, is of steel moment resisting frame construction (Building, Type 3, or Building Type 4 or 6 with dual lateral system, as defined in Section 2.2.3) and the building permit was issued after October 25, 1994.

2022 CAC, Article 11.01.2, Item 2
The building is designated “NPC 4” in conformance with Table 11.1 “Nonstructural Performance Categories” and provided:
a. The building was designed and constructed under a building permit issued by HCAI, and
b. All subsequent repairs, remodels, additions and alterations were performed under a permit issued by HCAI, and
c. Fire sprinkler systems have been retrofitted in conformance with Table 11.1, “Nonstructural Performance Categories.”

Per Table 11.1, Fire sprinkler systems shall comply with the bracing and anchorage requirements of NFPA 13, 1994 edition, or subsequent applicable standards, effective date April 30, 1996 (Emergency Adoption).

3. Include a Matrix of Construction per 2022 CAC, Chapter 6, Section 1.3.4, Item 6, page 86.
   

4. Submit an amended or revised site plan showing the location of the building(s) to be added. We also recommend including approved drawings for this building (PDF format is acceptable, oversized documents that are too large for email, CD or USB may be uploaded using our Secure File Transfer (SFT) website, click to request an SFT link). This will expedite the review as it takes time to retrieve the drawings from HCAI archives.

The SCU will assign SPC 5/NPC 4 to the building if the project under which the building was built is closed in compliance.

9. How do I remove Acute Care Services from a hospital building?#

Please see eSP User Guide Applying for Removal of Acute Care Services. The 3-step process is summarized below;

Step 1: Submit a construction project using the eServices Portal (eSP)#

If no construction is required for the removal of acute care services, this step may be skipped.

If construction is required to remove acute care services from a building submit one or more application(s) for new project to the Building Safety Section using the eServices Portal (eSP). See eSP User Guide Applying for Removal of Acute Care Services Section 3.1 for more information.

The project should demonstrate that the hospital building is eligible to have acute care services removed and that it can be transferred to either the local jurisdiction or remain in HCAI jurisdiction as a non-hospital building (this may include Acute Psychiatric or Skilled Nursing uses). 

The 2022 California Existing Building Code, Section 309A outlines the requirements for such a project. Also see CAN 1-6-1.4.5.1.4 for examples on this issue, even though it has been superseded by the 2022 California Building Code. For further questions, contact the supervisor of the appropriate region of the Building Safety Section of HCAI/OSHPD where the building is located. 

Step 2: Submit a no-construction project using the eServices Portal (eSP)#

Once the construction project(s) from Step 1 have been completed and closed in compliance, submit a no-construction application for new project to the Building Safety Section using the eServices Portal (eSP). See eSP User Guide Applying for Removal of Acute Care Services Section 3.2 for more information.

Step 3: Submit a Removal of Acute Care Services (RACS) project to the Seismic Compliance Unit (SCU)#

Once the no-construction RACS project from Step 2 has been completed and closed in compliance, submit an application to the SCU and include the following:

1. Complete the first 4 pages of HCAI-OSH-121 Application for New Project.
   • For Project Type, under Removal of Acute Care Services, select HCAI Jurisdiction or Local Jurisdiction.

2. Where HCAI jurisdiction is requested, provide the RACS project number and approval letter.

3. Where Local jurisdiction is requested, provide the letter written by the supervisor of the appropriate region that hands the jurisdiction of the building to local authorities.

4. Submit an amended or revised site plan showing the location of the buildings that remain in HCAI jurisdiction.

We also recommend including approved drawings for the RACS project (PDF format is acceptable, oversized documents that are too large for email, CD or USB may be uploaded using our Secure File Transfer (SFT) website, click to request an SFT link). This will expedite the review as it takes time to retrieve the drawings from HCAI archives.

The SCU will then reclassify the building as OSHPD 1R and remove it from the list of buildings that need to comply with Senate Bill 1953.  Where the building is being handed to local jurisdictions, the building is removed from the list of hospital buildings all together.

10. How are demolished buildings removed from the OSHPD building inventory?#

Once the buildings have been demolished, submit an application to the Seismic Compliance Unit (SCU) and include the following:

1. Complete the first 4 pages of HCAI-OSH-121 Application for New Project.
   • For Project Type, under Seismic Retrofit Program, select Application for Seismic Evaluation Report.
   • On page 2 for Record Detail write “Demolition of Building” in the Record/Project Name.

2. Submit an amended or revised site plan showing the location of the remaining buildings.

3. Submit relevant sheets of permit drawings under which the building was demolished (PDF format is acceptable, oversized documents that are too large for email, CD or USB may be uploaded using our Secure File Transfer (SFT) website, click to request an SFT link).

4. Submit a Field Staff Report showing start or completion of demolition or demolition progress photographs.

The SCU will then remove the building from the list of hospital buildings.

11. What is the Detailed Frame Joint Evaluation procedure for Pre-Northridge Moment Frame Buildings after an earthquake?#

This is a 3-step process:

Step 1: Submit an application to the Seismic Compliance Unit (SCU)#

Submit an application for a Complete Joint Penetration (CJP) Joint Inspection Program to the SCU per the 2022 California Administrative Code, Chapter 6,  Section 4.2.0.3 where buildings have exceeded the ground motion specified in 2022 CAC Chapter 6, Section 4.2.0.1. 

2022 California Administrative Code (CAC), Chapter 6

4.2 Steel moment frames. Welded steel moment frames may be subject to detailed frame joint evaluation requirements, as outlined in this section. The purpose of this joint evaluation is to determine if the building has experienced joint damage in strong ground shaking.

4.2.0.1 Preliminary screening. All welded steel moment frame structures shall undergo a detailed frame joint evaluation if the building is located at a site that has experienced the following:
1. An earthquake of magnitude greater than or equal to 6.5 that produced ground motion in excess of 0.20g; or
2. An earthquake that generated ground motion in excess of 0.30g.
The ground motion estimates shall be based on actual instrumental recordings in the vicinity of the building. When such ground motion records are not available, ground motion estimates may be based on empirical or analytical techniques. All ground motion estimates shall reflect the site-specific soil conditions.

4.2.0.2 Additional indicators. A detailed frame joint evaluation of the building shall be performed if any of the following apply:
1. Significant structural damage is observed in one or more welded steel moment frame structures located within 1 km of the building on sites with similar, or more firm, soil properties;
2. An earthquake having a magnitude of 6.5 or greater, where the structure is located within 5 km of the trace of a surface rupture or within the vertical projection of the rupture area when no surface rupture has occurred;
3. Significant architectural or structural damage has been observed in the building following an earthquake; or
4. Entry to the building has been limited by the building official because of earthquake damage, regardless of the type or nature of the damage.

4.2.0.3 Connection inspections. Detailed frame joint evaluations shall be performed in accordance with the procedures in the Interim Guidelines: Evaluation, Repair, Modification and Design of Welded Steel Moment Frame Structures, FEMA 267, August 1995_.

Accessibility requirements for Detailed Frame Joint Evaluation Procedure for Pre-Northridge Moment Frame Buildings:

The detailed frame joint evaluation procedure for pre-Northridge moment frame buildings involves a visual, ultrasonic or magnetic particle inspection of moment frame joints in an existing building. As the inspections of the joint by itself does not constitute a “building alteration, structural repair or addition”, accessibility requirements of Chapter 11B of 2022 California Building Code do not apply. Spray-on-fireproofing or other fireproofing materials removed from the moment frame joint for the purposes of the inspection also do not constitute a “building alteration, structural repair or addition” where they are replaced in kind soon after the inspection (may be subject to special inspection under Section 1705A.14 Sprayed Fire-resistant materials). Where non-structural framing, finishes and/or ceiling systems are removed or altered temporarily to gain access to the joint, and then replaced in kind, the accessibility requirements apply only when the work performed exceeds an amount that would normally be required to gain access to the moment frame joint – a rule of thumb used in such cases is accessibility requirements apply when more than 25% of the ceiling in a room is temporarily removed/altered. Any repair, removal or alteration and replacement of structural systems such as beams, bearing and/or shear walls, will trigger accessibility requirements of Chapter 11B of the 2022 California Building Code, see examples in CAN 2-11B.

Step 2: Submit a construction project using the eServices Portal (eSP)#

After the CJP Joint Inspection Program is approved, submit an application for new project to the Building Safety Section using the eServices Portal (eSP). Obtain a building permit and perform the joint inspection.

Step 3: Submit an application to the Seismic Compliance Unit (SCU)#

Submit an application for CJP Joint Inspection Results to the SCU. If there is no damage, the SCU will concur with the results of the joint inspection and close the CJP Joint Inspection Program and Results projects.

Perform additional joint inspections depending on a damage index based on the results of field joint inspection where required. If damage is found, the SCU will discuss possible repair projects with the responsible design professionals.

Additional Notes:

• The joint inspections for affected buildings should be completed within six months after the earthquake.
• The joint inspection project should be left open until the SCU concurs with the results.
• Include notes on the process for inspection (2013 processforinspections.doc) with the joint inspection project.
• The joint inspection project will be reviewed by a fire marshal to verify replacement in kind of the fire proofing removed for the joint inspection.

12. Do buried tunnels have SPC or NPC ratings?#

Buried tunnels connecting hospital buildings that are not used for public egress (such as utility tunnels with just service personnel access) receive NPC ratings only.

Buried Tunnels for public use (such as tunnels linking the basements of multiple hospital buildings) are required to have SPC and NPC ratings. The actual use of the tunnels may be verified by HCAI field staff.

Seismic Performance Category (SPC)#

1. Can I submit a letter declaring the seismic performance category of a hospital building instead of a detailed Seismic Evaluation Report?#

Per 2022 California Administrative Code, Sections 2.0.1.2 (SPC) and 11.01.2 (NPC) list the specific conditions where a hospital facility owner can submit a written declaration and be exempt from submitting either a structural or nonstructural evaluation report. However, the matrix of construction information specified in Section 1.3.4.6 shall be submitted pursuant to the requirements of Section 1.3.1. There are no other provisions for exemption from the Seismic Evaluation Report.

2. What if I don′t have any existing drawings?#

When performing the structural evaluation for a hospital building without existing drawings or sufficient construction documents, as-built drawings as required by 2022 CAC, Chapter 6, Sections 2.1.2.1.1 and 2.1.2.2.2 shall be rendered to determine the SPC category of the specified hospital building. Refer to Sections 11.2.1.2, Item (d); 11.2.2, Item (e) and 11.2.3, Item (e), when performing the nonstructural evaluation to determine the NPC category of a hospital building without existing drawings or sufficient construction documents.

Additionally, the Seismic Evaluation Report and Compliance Plan/Schedule submittal process does not require original construction documents, only the information specified in Sections 1.3 and 1.4 and their respective subdivisions.

3. Is HCAI′s expectation that an SPC 2 upgrade provides a “Life Safety” level of performance?#

The various levels of structural seismic performance established by SB 1953 include potential collapse hazard (SPC 1) to immediate occupancy (SPC 5) after a seismic event. The SPC 2 may not be repairable or functional after the event and, therefore; unable to provide general acute care hospital services. Buildings reclassified to SPC 2 on the basis of their collapse probability assessment (HAZUS) have a calculated probability of collapse which increases with the presence of significant structural deficiencies in the building.

4. Is HCAI′s expectation that an SPC 5 upgrade provides an “Immediate Occupancy” level of performance?#

The various levels of seismic performance established by SB 1953 include potential collapse hazard (SPC 1) to immediate occupancy after a seismic event (SPC 5). The SPC 5 subgradation is currently the highest level of seismic structural performance. After a seismic event, it is anticipated that a SPC 5 facility will survive; suffering only very limited structural damage and will be able to provide full general acute care patient services (i.e. immediate occupancy).

5. How do I apply for an SPC 4D Material Testing and Condition Assessment Program (MTCAP) and Results (MTCAR) project?#

The following steps explain the process for SPC 4D Material Testing and Condition Assessment Program and Results. However, the steps described below apply to any type of material testing projects (i.e. same for material testing required by SPC 2 “Usual Level” or SPC 4D “Comprehensive Level”).

Step 1: Submit an application to the Seismic Compliance Unit (SCU)#

Submit an application for SPC 4D Material Testing and Condition Assessment Program (MTCAP) to the SCU and include the following:

1. Complete the first 4 pages of HCAI-OSH-121 Application for New Project.
   • For Project Type, under Seismic Retrofit Program, select Application for Seismic Evaluation Report.
   • On page 2 for Record Detail write “Material Testing and Condition Assessment Program (MTCAP)” in the Record/Project Name.

2. Submit complete MTCAP documents, detail drawings and specifications. Material Testing Program (MTP) and Condition Assessment Program (CAP) Programs can be submitted separately.

3. The SCU will then review the structural scope of the MTCAP, the detail drawings and specifications. After the SCU approves the MTCAP the project will be closed. The SCU typically stamps the cover page of the report and sends the approved MTCAP report back to the Applicant.

Step 2: Submit a construction project using the eServices Portal (eSP)#

Submit an application for new project to the Building Safety Section using the eServices Portal (eSP) and include the following:

1. A copy of the SCU approved MTCAP Report and approval letter.

2. Construction documents, which shall include all of the following:
   • An overall building floor plan showing the proposed locations of inspection;
   • Emergency procedures for construction workers;
   • Details and requirements for restoration of finishes and/or fire rated assemblies;
   • When inspection impacts means-of-egress, a temporary exiting plan;
   • Plans and details for temporary construction barriers;
   • Fire watch procedures: When it is not possible to maintain fire-resistive assemblies, fire-resistive construction and/or the means of egress, temporary construction barriers and/or a fire watch shall be provided in accordance with HCAI/OSHPD PIN 14.

3. Specifications

4. TIO form

(These projects may be processed in accordance with the FREER Manual as a Field Review project)

HCAI/OSHPD region review includes architectural, structural, fire/life safety. Electrical or mechanical review are typically not required.

After the HCAI/OSHPD region approves the project and issues a permit for the MTCAP project, the construction phase (i.e. testing) begins.

During the Conditions Assessment, fire-resistive assemblies, fire-resistive construction and the means of egress shall be maintained in accordance with Chapters 7 and 33 of the California Fire Code. These plans and procedures shall be reviewed and approved by the HCAI field staff (Compliance Officer, Fire and Life Safety Officer and District Structural Engineer) and the local fire authority (as applicable) in accordance with Section 3301 of the 2022 California Fire Code. Compliance with the provisions of Chapter 33 of the 2022 California Fire Code are in addition to any additional regulations or requirements pertaining to dust control, noise control and asbestos abatement enforced by agencies other than HCAI/OSHPD.

When demolition, inspection and reconstruction is continuous, no hot work is involved and inspectors and construction workers are in constant attendance, enforcement of temporary construction barrier and / or fire watch requirements may be deferred. Under these conditions, appropriate procedures shall be established in the event of a fire or other emergency.

During sampling stage, if any deviation from the MTCAP report occurs, such as sampling location, number of samples etc., SCU shall be notified immediately via email with a brief description of the change, a photo and any additional supporting documentation. To prevent any construction delays, SCU will respond back via email as soon as possible (Keep track of these responses, as these communications will be required in the MTCAR report).

Where changes are extensive, an amended construction document may be required at the discretion of the District Structural Engineer in consultation with the SCU.

The SCU recommends that the project remain open (within time limitations per 2022 CAC 7-129) until the results are accepted by the SCU in case additional testing or inspection is required.

Step 3: Submit an application to the Seismic Compliance Unit (SCU)#

Submit an application for SPC 4D Material Testing and Condition Assessment Results (MTCAR) to the SCU and include the following:

1. Complete the first 4 pages of HCAI-OSH-121 Application for New Project.
   • For Project Type, under Seismic Retrofit Program, select Application for Seismic Evaluation Report.
   • On page 2 for Record Detail write “Material Testing and Condition Assessment Results (MTCAR)” in the Record/Project Name.
2. Submit complete MTCAR reports, include all deviations, and corresponding SCU approval emails.

3. The SCU will issue and MTCAR approval letter and close the project.

4. Contact the Building Safety Section and request to close the construction project.

6. What material standard version should be used for SPC-4D building design per ASCE 41-13? For example, ACI 318-11 (referenced in ASCE41-13 Chapter 17) or ACI 318-19 (current code CBC 2022 Chapter 35)?#

It is acceptable to use ASCE 41-13 Chapter 17 referenced standards or later versions.

7. What does “Not a Building Structure” on the HCAI website mean?#

“Not a Building Structure” are buildings that are not intended for occupancy by people except for maintenance and other intermittent access and that are not constructed in the manner of a building. Examples of buildings that are classified as Not a Building Structures are:

1. Cooling Towers
2. Elevated platforms supporting equipment
3. Fabricated bolted together enclosures such as emergency generator sound enclosures
4. Tank structures

Nonstructural Performance Category (NPC)#

1. The continuous operation issue is to be addressed for hospitals that are to remain in existence beyond the 2030 deadline. Prior to 2030 deadline, why does the Nonstructural Performance Category (NPC) 3 category require components that are part of continuous operation systems to be anchored and braced, when located in critical care areas and other support areas critical to patient care?#

The NPC′s were developed with the intent of establishing various levels of seismic performance for nonstructural equipment, components and systems critical to patient care. The critical distinction between any two NPC′s is not merely the survivability of the facility, but its level of functionality after a seismic event. Nonstructural components and systems have a lower threshold to seismic forces than structural elements and systems.

Buildings in the NPC 3 category are expected to maintain their inpatient population following a moderate earthquake, as well as provide a full array of emergency services to the public. To enable a NPC 3 hospital building to provide these level of services (i.e. beyond mere survivability and be able to provide a minimal amount of medical care in specific areas) it is necessary to provide the bracing and anchorage specified in California Administrative Code, Chapter 6, Table 11.1, Nonstructural Performance Categories.

2. Do critical care areas such as Emergency Rooms, which are not part of the required Basic Services, have to meet the requirements of NPC?#

In 2022 CAC, Chapter 6 Section 1.2, Definitions, the term “Critical Care Area” is defined as “those special care units…in which patients are intended to be subjected to invasive procedures and connected to line-operated, electromedical devices.” Within this definition, “emergency rooms” is listed as a type of critical care area. The 2022 California Administrative Code, Chapter 6, Table 11.1 lists “Critical Care Areas” in NPC 3 as an area where specified components/equipment/systems must meet the bracing and anchorage requirements of Part 2, Title 24. Therefore, “emergency rooms” must meet the requirements as specified in the NPC 3.

3. Would a Neurocare Ward (not ICU) with patients hooked up to a ventilator fall under the definition of “critical care”? Also, would a telemetry unit be considered “critical care” area?#

A neurocare ward would be considered a “critical care” area due to the nature of the treatment for the patients placed in them or the type of service provided (e.g. postoperative from brain surgery, etc.). A telemetry unit need only be considered for evaluation purposes if it supports a critical care area. In this context, a “telemetry unit” is defined as a group of patient beds with remote monitoring.

4. CAC 2022 Table 11.1 for NPC 4 says “and all architectural, mechanical, electrical systems, components and equipment”. Does this mean that the NPC 3 Exceptions do not apply? (i.e. seismic bracing for cable trays, conduits and HVAC are not excluded anymore)#

NPC 4 includes all electrical, mechanical, architectural. So, if NPC 4 upgrade in a NPC 3 building is desired, NPC 3 exceptions items are also required to be braced and anchored per 2022 CAC Chapter 6 Table 11.1. In other words, all components and equipment are required to be anchored and braced per Part 2 Title 24 under NPC 4. Alternate path forward can be NPC 4D route, where you can follow NPC 3 exceptions.

5. One of our hospital buildings does not have fire sprinklers. If this building is seismically retrofitted to SPC 2 level, will this require us to install a fire sprinkler system? What if it is retrofitted to SPC 5 level?#

Sprinkler systems fall under the Nonstructural Performance Categories (NPC′s) and not under the Structural Performance Category (SPC) requirements. Compliance with SB1953 does not require that fire sprinkler systems be installed where none existed before, even for SPC 5 conformance. However, hospital buildings with existing fire sprinkler systems must meet the anchorage and bracing requirements of NPC 3 and NPC 4.

6. Are there areas within a typical hospital where the Nonstructural Evaluation requirements of SB 1953 do not apply?#

The answer to this question depends on the desired NPC level of performance. Table 11.1, Nonstructural Performance Categories, determines the applicability of the nonstructural evaluation requirements for a hospital. If the desired performance level is NPC 4 or 5 (for acute care operation beyond 2030) then all areas of the hospital are subject to the requirements as listed in California Administrative Code, Chapter 6, Table 11.1. However, NPCs 2, 3 and 4D primarily impact critical care areas of a hospital, with adjacent non-critical care areas affected by presence of specific systems (e.g. communications, emergency power, means of egress, fire alarm and med-gas) as delineated in California Administrative Code, Chapter 6, Table 11.1.

7. Are single line diagrams required for the location of certain hospital areas?#

The Nonstructural Evaluation Report (see 2022 California Administrative Code, Chapter 6, Article 1, Section 1.3.4, Item 2.1) must include single line diagrams for the location of the following:

• Central supply areas
• Clinical laboratory service spaces
• Critical care areas
• Pharmaceutical service spaces
• Radiological service spaces
• Sterile supply areas

There are no provisions requiring single line diagrams for other hospital areas.

8. What is meant by “description…where deficiencies are identified” in Section 1.3.4, Item 2.2 of Article 1?#

Nonstructural elements and systems which do not meet the requirements of Article 11 should be reported as deficiencies. These deficient systems/elements should be described in the nonstructural evaluation either in narrative or diagrammatic format as specified in 2022 California Administrative Code, Chapter 6, Article 1, Section 1.3.4, Item 2.2.

The essential aspects of this description shall include identification and location of deficiencies within specific building systems including but not limited to the mechanical, plumbing, and electrical systems of the building and their respective components which fall within the scope of the nonstructural evaluation.

9. Often in hospital corridors the ceiling space is filled with pipes and conduits. Is it acceptable to create a secondary frame to “catch” the pipes to protect the exiting corridors instead of bracing all the pipes?#

Though catching the pipes is important, it is not the primary issue. In addition to the potential as a falling hazard that the pipes may represent, it is also important to prevent escape of the pipes′ contents should the pipes break. Proper anchorage and bracing will reduce movement and shearing of pipes, and thus reduce the possibility of the escape of the contents. Therefore, the anchorage and bracing of pipes and conduits must meet the requirements of Chapter 16A, Part 2, 2022 California Building Code. Secondary framing is an option available for pipe bracing, but is dependent on site conditions.

10. Regarding air handlers that are functionally inadequate and have to be braced, do I have to replace them?#

No, all that is required is that the air handlers be braced and anchored, not replaced.

11. If the intent of NPC 3 is to prevent loss of water from pipes in critical care areas, do we have to brace pipes from the central plant to the critical care areas? We infer the intent to prevent water loss from the valving option permitted. Can we only valve the pipes at the boundaries of critical care?#

Pipes from the central plant supplying or passing through the areas specified in the NPC 3 category do not need to be braced outside the boundaries of those areas. However, equipment anywhere in the physical plant that services the NPC 3 specified areas shall be anchored and braced.

NPC 3 Exception 1 permits piping systems not be anchored and braced until 2030 (or 2024 based on Seismic Design Category F)  provided that “an approved method of preventing release of the contents of the piping system in the event of a break is provided.” Valving the piping system is an acceptable method of preventing the escape of the pipe systems contents in the event of pipe breakage or shearing. The configuration of the valving layout depends on the layout of the piping within the NPC 3 specified areas. It should be noted that valving the pipes only at the boundaries may or may not prevent the release of pipe contents in those areas.

12. Could a policy be established which would clearly delineate the equipment within a hospital that would be affected by SB 1953?#

No. As medical and other types of equipment vary from hospital to hospital, it is impractical to establish a policy with a definitive list of equipment which would be affected by SB 1953. The evaluation procedures and evaluation (appendix) questions delineate the conditions, equipment, systems, and components which fall under the general scope of the seismic evaluation.

13. In CAC Chapter 6 Article 11, the NPC process involves first a complete survey, then determining whether an HCAI permit exists, then making an NPC designation. This infers that in a code compliant structure, we have to do the whole survey even though it was built with full inspection. Can we not rely on an HCAI permit and inspection to designate the structure as compliant?  Is it acceptable to look for permits first, and then survey the non-compliant areas?#

The evaluator is free to perform the nonstructural evaluation in any manner desired. Hospital buildings constructed under a permit issued by HCAI are deemed to comply with the anchorage and bracing requirements of Title 24, with the exception of the fire sprinklers (unless constructed or retrofitted under NFPA 13, 1994 or subsequent edition). For other types of buildings, a review of the available drawings to determine the extent of the nonstructural bracing prior to conducting the site visit is very prudent. Aside from establishing the level of anchorage and bracing required to be expected, it will allow the evaluator to inventory components appearing on the drawings that should be braced. As a rule all major components that require bracing should be shown on the drawings. It is important to note that the NPC 3 evaluation is limited to those systems and components listed in the 1995 CBC, Part 2, Title 24, Table 16A-O.

All compliant buildings are not the same. Between 1973 and 1983, the enforcement of the code requirements for nonstructural elements, components and systems was inconsistent. The level of attention given to nonstructural bracing varied tremendously. This is substantiated by the nonstructural failures that occurred in various post-1973 hospitals as a result of the Northridge Earthquake.

In the late 1970′s and 1980′s some pre-1973 buildings had extensive remodels. The scope of these remodels can vary extensively, from cosmetic alterations to a complete gutting of the space, with reconstruction to current standards. It is not unusual to find braced and unbraced components next to each other in the same space. If the component or system was not modified during the remodel, then it was probably not seismically retrofitted. Only by inventorying the systems can the extent of the seismic bracing be definitively established.

14. Do hospital facilities need to meet the requirements of NPC 5 now?#

For existing buildings, the milestone date for NPC 5 compliance is January 1, 2030 per 2022 California Administrative Code, Chapter 6, Table 11.1.

However, if a new seismically separate general acute care hospital building greater than 4000 square feet is constructed, it is required to be NPC 5 compliant per Section 1617A.1.40 of the 2022 California Building Code. Only the new building is required to be NPC 5 compliant and not the entire facility.

15. Is NPC 5 a campus-wide designation (like NPC 2) or a seismically separate building designation?#

NPC 5 is a campus-wide designation with compliance expected in 2030, but new seismically separate buildings constructed to the 2010 or later California Building Codes are required to be NPC 5 compliant now. HCAI recommends planning to comply on a campus-wide basis with a phased approach to get NPC 5 compliance for a new building before it’s occupancy.

16. Is a hospital facility required to have storage tanks for 72 hours of water, sewage and liquid waste? The required tanks are too big and our site does not have the room for placement of such tanks.#

NPC 5 refers to the ability of a hospital facility to support 72 hours of emergency operations. The California Plumbing Code has exceptions (see Sections 615.4 and 727.0 of the 2022 California Plumbing Code) that allow much smaller holding tanks where alternate arrangements have been made for delivery of water or transportable means for sewage and liquid waste disposal. Where such exceptions are used, the arrangements require approval by HCAI and the California Department of Public Health.

17. Does the NPC 5 requirement of 72 hours of water refer to potable water only? Is industrial water or (process) water to operate hospital utilities included in this storage requirement?#

NPC 5 requirement refers to both potable water as well as industrial/process water to operate hospital utilities to support 72 hours of emergency operations:

For a seismically separate building that has licensed patient beds, a minimum of 150 gallons of potable water per licensed bed shall be provided (Section 615.4, 2022 California Plumbing Code) with additional industrial/process water to support 72 hours of emergency operation of the subject building. Also see exception in California Plumbing Code Section 615.4.1, for a seismic separate building that has no licensed patient beds, potable water and industrial/process water to support 72 hours of emergency operation of the subject building. A new Central Utility Plant must provide water for 72 hours of emergency operation for itself, any other new buildings but not for the existing buildings on the campus (The existing buildings will need to comply by 2030).

The amount of water required is determined from the facility’s emergency operations plan and an associated Water Conservation/Water Rationing Plan to provide for 72 hours of operation. The water conservation/water rationing plan must also be accepted by the California Department of Public Health licensing division. Whereas, there is a minimum volume of potable water per licensed bed, there is no minimum volume for industrial/process water in the California Plumbing Code. This volume is dependent on which utilities and systems the hospital facility intends to operate during an emergency. The Water Conservation/Water Rationing Plan must account for losses in the process water for closed loop heating and cooling systems.

See a planning guide titled “Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities” published by DHHS, CDC and AWWA.

HCAI review of NPC 5 will be based on the volume of water required by the facility’s Water Conservation/Water Rationing Plan (as part of the facility’s emergency operations plan) as required by the California Plumbing Code.

18. Does the facility have to comply with Section 615.4.2 of the 2022 California Plumbing Code even when using the exception in Section 615.4.1?#

Section 615.4.2 of the 2022 California Plumbing Code requires the emergency supply of water be provided with sufficient pressure using gravity, pressure tanks or booster pumps. If booster pumps are provided, they are required to be connected to the emergency power supply system.

Section 615.4.2 applies even when the exception of Section 615.4.1 of the California Plumbing Code is used, to ensure that the emergency supply of water is delivered to the end point of usage at sufficient pressure from the storage tank. The ability to dispense water to portable containers from the storage tank required in the exception of Section 615.4.1 of the California Plumbing Code is to be considered a measure of last resort.

19. Per Section 727 of the 2022 California Plumbing Code, can the facility store the sewage and liquid waste in a 5,000-gallon tank? Does this tank need to be connected to a sewage line?#

Yes, holding tanks are required; however, there is no minimum size for the holding tank provided in Section 727, 2022 California Plumbing Code. The capacity shall be based on the Water Conservation/Water Rationing Plan required in Section 615.4.1.

The purpose of the holding tank is to permit 72 hours of continuing operation if the external sewer connection is severed. Thus, HCAI does not have any requirements for connection of the holding tank to the existing sewer line; however, such connections should be made with sufficient valves to isolate the external sewer lines.

20. Can we use bladder tanks to store sewage and waste water in the parking lot?#

The exception to Section 727, 2022 California Plumbing Code permits use of leak-proof bags where adequate storage for such bags is provided where they comply with the appropriate local health and environmental authorities’ requirements, California Department of Public Health requirements for medical waste management AND requirement for location as well as enclosure.

HCAI takes no objection for use of the parking lot or any other location for storing these bags, if the storage location complies with the requirements of a lockable screen enclosure, floor, curb, drain connected to a sewer and supply of water as enumerated in this exception.

21. For NPC 5 evaluations, is the on-site emergency fuel storage requirement based on 96 hours or 72 hours? Are the fuel storage requirements based on fuel consumption of the generators at rated capacity or the actual load for the facility? Does the fuel storage requirement apply to N configuration only?#

HCAI enforces a minimum of 72 hours of fuel storage for NPC 5 buildings, and not the 96 hours required by NFPA 101.However, NFPA 110 requires the main fuel tank(s) to have on-site fuel storage of at least 133% of the quantity required. Requirements for on-site fuel storage requirements for various healthcare buildings can be found in the 2022 CEC article 700.12.

As stated in NFPA 110 5.1.1.1 “on-site storage of an alternate energy source sufficient to allow full output of the EPSS to be delivered for the class specified shall be required.” For acute care hospitals, the class is 72, therefore the minimum on-site storage tank capacity requirement is 133% of the calculated 72-hour fuel supply to support fully loaded generator(s).

The minimum on-site fuel storage for an existing acute care hospital facility required to meet NPC 5 requirements shall be based on the actual load [“full-demand” on the Essential Electrical System (EES) per the 2022 California Electrical Code Section 700.12 (B)(2)]. The full demand load of the existing EES should be calculated by following the method described in HCAI PIN 38 for level-one panel existing demand loads. The full-demand metered load taken at 125% should be used to determine the minimum number of generators required to meet or exceed the full-demand load at a particular site. Fuel sufficient to operate the minimum required generators at 100% for 72 hours shall be required. Note that for a N+1 configuration, fuel sufficient to operate only N generators is required.

Here is an example calculation to demonstrate these requirements.

Existing site has (3) 1500 kW/1875 kVA emergency generators. Facilities existing max demand load for the essential system is 2.9 MVA. [2.9 MVA x 1.25 = 3.625 MVA]

Therefore, the facility needs (2) 1500 kW/1875 kVA generators to meet site essential loads. Manufacturers listed fuel consumption for 1500 kW generators 100% loaded (full output) is 106.5 gal per hour.

• 106.5 gal/hour * 72 hours * 1.33 = 10,198 gallons
• 10,198 gallons * 2 generators = 20,396 gallons

Minimum on site fuel storage is 20,396 gallons.

22. What is NPC 3 upgrade requirements for GAC buildings that do not contain critical care spaces noted in 2022 California Administrative Code, Chapter 6, Article 11, Table 11.1?#

The facility needs to submit a formal request for NPC 3 upgrade when a building does not contain any of the critical care spaces noted in the NPC 3 description.  The NPC 3 upgrade request needs to provide a functional layout for all the areas in the building showing what the various areas are used for.  Also, if equipment serving the critical care areas in other buildings is in the building in question, then a full NPC 3 upgrade would be required.

23. What are the NPC 4 and NPC 5 evaluation deadlines and requirements for buildings that will be removed from acute care service by the January 1, 2030 deadline?#

Please see General Questions FAQ #9 for detailed instructions on submitting Removal of Acute Care Services (RACS) projects.

2022 California Administrative Code, Chapter 6, Article 1, Section 1.5.2.1

1.1. By January 1, 2024, the hospital owner shall submit to the Office a complete nonstructural evaluation up to NPC 4 or 4D and NPC 5, for each building. 

The NPC 4/NPC 5 evaluation shall consist of a letter from the hospital (on hospital letterhead, signed by the Administrator/CEO) stating that BLD-xxxxx will be removed from acute care usage by January 1, 2030.  This letter will need to be submitted as part of a Seismic Compliance Unit (SCU) project.

2022 California Administrative Code, Chapter 6, Article 1, Section 1.5.2.1

1.2. By January 1, 2026, the hospital owner shall submit to the Office construction documents for NPC 4 or 4D and NPC 5 compliance that are deemed ready for review by the Office, for each building that will continue to provide acute care services beyond January 1, 2030. 

The facility will need to submit one or more RACs construction projects to meet the requirements of applying for Removal of Acute Care Services. If no construction is required for the removal of acute care services, then this step may be skipped.

2022 California Administrative Code, Chapter 6, Article 1, Section 1.5.2.1

1.3. By January 1, 2028, the hospital owner shall obtain a building permit to begin construction, for NPC 4 or 4D and NPC 5 compliance of each building that the owner intends to use as a general acute care hospital building after January 1, 2030. Hospitals not meeting the January 1, 2028 deadline set by this section shall not be issued a building permit for any noncompliant building except those required for seismic compliance in accordance with the California Administrative Code (Chapter 6), maintenance, and emergency repairs until the building permit required by this section is issued. 

RACs construction project(s) shall obtain building permit(s) by January 1, 2028.  After closure of these projects in compliance, a no construction RACs project shall be submitted to the Office, as per the eSP User Guide Applying for Removal of Acute Care Services, indicating whose jurisdiction the building will be in (local authority having jurisdiction or HCAI/OSHPD).  Once that project is closed in compliance, submit a project to the SCU by January 1, 2030, to remove the building from the acute care building inventory.

24. Can I upgrade from NPC 2 to NPC 4 or NPC 4D Level X directly? Or do I need to upgrade from NPC 2 to NPC 3, and then from NPC 3 to NPC 4 or Level 4D Level X?#

The NPC upgrade can go directly from NPC 2 to NPC 4 or NPC 4D Level x.

25. Link to 1995 CBC Table 16A-O#

1995 CBC Table 16A-O

26. Link to 1998 CBC Table 16B-O#

1998 CBC Table 16B-O

27. Limits of Critical Care Areas#

2022 California Administrative Code (CAC), Chapter 6, Article 1, Section 1.2 – CRITICAL CARE AREA means those special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, emergency rooms, operating rooms, postoperative recovery rooms and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, electromedical devices.

In the case of a Surgical Services Department, for example, CBC 1224 calls for certain code required spaces such as staff locker rooms, nurse control office, etc. Because these rooms are required by code for a Surgical Services Department to function, must they also be considered Critical Care Areas? Or, do we take a strict definition of Critical Care Areas to include only spaces for patients?

The whole Surgical Services department would be the boundary of the NPC 3 critical care area.

28. Definition of an OSA Project#

2022 California Administrative Code Chapter 6, Article 11, Sections 11.2.1.c.2; 11.2.2.d.2; 11.2.3.c.2; and 11.2.4.c.2 describes an OSA project as;

Reviewed and approved by the Department of General Services, Office of Architecture and Construction, Structural Safety Section. Drawings showing: a) the installation; b) bear an Office of Architecture and Construction, Structural Safety Section approval stamp; and c) a five-digit project number on the approval that begins with the “H” prefix,…

The leading “H” is counted as a digit in this description. The actual description is the OSA project number starts with an “H” followed by 4 digits.

29. Using the 1987, 1989, 1991 NFPA 13 to show compliance with fire sprinkler bracing#

Scope of Work

1987, 1989, 1991 edition NFPA 13 Building Scope:

1. Buildings where fire sprinklers are designed with 1991 edition NFPA 13: Design team required to add missing end-of- line restrains only.
2. Buildings where fire sprinklers are designed with 1987 and 1989 edition NFPA 13: Design team to perform a visit site and verify original branch line bracing and end-of-line restrains exist. Design team required to add missing end of branch line restrains, missing longitudinal sway bracing for feed and cross mains, and missing lateral sway bracing for feed and cross mains.

1985 edition and earlier NFPA 13 Building Scope:

1. Buildings where fire sprinklers are designed with 1985 and earlier NFPA 13: All fire sprinkler piping above ceiling shall be evaluated.

Existing Documentation

1. Photo Documentation: For projects constructed under the 1987, 1989, and 1991 edition NFPA 13 if the design team observes either end of line restrains and/or branch bracing, photo documentation will be sufficient to accept the as-built condition as part of an engineering report signed and stamped by the Structural Engineer of Record. However, the amount of photo documentation will need to be discussed, reviewed, and approved by the SCU.

Design Criteria

1. Anchorage Design: Where new restraints or bracing is placed, the anchorage design shall meet current California Building Code.
2. Location of Bracing and End-of-Line Restraints: The number and location of bracing or end-of-line restraints will be identified per Scope of Work above.

30. For NPC 4D operational plan, 2022 CAC Chapter 6 Article 11.2.3.(f) states  “..As-built plans, schematic, or other means showing the routing for all utilities serving the areas from their source to the areas they serve…”. There seems to be confusion on how much piping/conduits/ducts need to be shown. Are small pipes/conduits/ducts that are code exempt from bracing need to be shown on the schematic utility plan?#

Although it is desirable to have of all exempt and non-exempt utility line drawings on hand, it is often not feasible. Therefore it is acceptable to show only non-exempt distribution systems in the NPC 4D operational plan .

31. Where can I find the California Department of Public Health Licensing and Certification All Facility letter (AFL 23-21)?#

AFL 23-21

32. Are calculations for sizing of emergency generator fuel tanks for 72 hour minimum run time required to be submitted as part of the January 1, 2024, NPC 5 evaluation?#

Yes.  If the emergency generator fuel tanks are used for other purposes, that usage needs to be addressed in the calculations.

33. Can buildings and tunnels with an OSHPD approved NPC 4D Level 1, 2, or 3 rating supply services/systems and utilities to conforming buildings (SPC-3, -4, -4D, or -5) downstream?#

2022 California Existing Building Code, Section 310A.1.1.1.1 does allow the use buildings or tunnels with an OSHPD approved NPC 4D Level 1, 2, or 3 rating to provide services/systems and utilities to conforming (SPC-3, -4, -4D, -5) buildings downstream of the NPC 4D Level 1, 2, or 3 building or tunnel. However, as part of the approval of the NPC 4D Level 1, 2, or 3 upgrade for these buildings or tunnels, the NPC 4D Operational Plan required by 2022 California Administrative Code, Chapter 6, Article 11, Section 11.2.3.f, shall address showing how for all critical care areas in the downstream buildings the facility will repair nonstructural damage and bring systems and services back on line for the downstream critical care areas, or provide downstream critical care areas in an alternative manner to accommodate continuation of critical care operations.

34. When citing a project to show a piece of equipment anchorage compliance, can I only cite the project, or do I need to cite the detail number, sheet number, and project number?#

Citing the project number is adequate to show anchorage compliance.

35. If the NPC 5 submittal is part of a package submitted by a licensed design professional, does it need to be sealed and signed by a licensed design professional?#

If the NPC 5 report is submitted by a licensed design professional, it needs to be signed and sealed by a licensed architect or mechanical engineer.

36. What are the NPC requirements for buildings from different eras?#

The table below lists the requirement for NPC 3, 4 and 4D⁷.

Approximate Year	Original Permitting Agency2	Self Declaration6	Equipment Inventory1	Distribution Systems Evaluation	Fire Sprinkler Evaluation	Calculations and Testing
Prior to 1973	Local	NA	R	R	R	Yes5
1973 to 1982	OSA2	NA	R	R	R	Maybe4
1982 to 1994 (1994 NFPA-13)	OSHPD3	Required	NR	NR	See FAQ #29	NR
1994 (1994 NFPA-13) to Present	OSHPD3	Required	NR	NR	NR	NR

37. What are the testing requirements for tension and shear for existing anchors?#

Demand, capacity, and testing requirements are listed under 2022 CAC Chapter 6 Article 11 §11.3 and clarified below for NPC-3, 4, and 4D:

1. Tension and shear demands shall be calculated per 1998 CBC §1630B as listed under 2022 CAC Chapter 6, Article 11, §11.3.
2. Tension and shear capacity for cast-in-place anchors shall be per Table 19B-E of the 1998 CBC. The tension and shear capacity for post-installed anchor tension and shear capacity is allowed to be per the ICC ER report matching the anchor manufacturer and code cycle at the time of installation.
3. Testing:
   • Tension: Refer to §11.3.1 and §11.3.2 for testing frequency, demand (3*tension), usage type (equipment versus distribution system), and permitted exceptions.
   • Shear: Shear testing or tension testing is not required when analysis indicates only shear demand (no tension).
   • Alternate testing criteria are permitted per §11.3.4.

38. If the design professional doing an NPC 4 reconciliation report determines that an area has not been constructed under an OSA or OSHPD project, but planned to be fully renovated later, can they note the renovation as future deficiency mitigation through a construction project?#

The NPC 4 upgrade and reconciliation report needs to note the areas that are deficient and compliant for the January 1, 2024 submittal deadline. The renovation project will need to be submitted to the Office by January 1, 2026; with a building permit issued by January 1, 2028; and construction being completed by January 1, 2030.

39. What is the minimum number of elevators required by NPC 4D Level 2 and NPC 4D Level 3 upgrades?#

There shall be a minimum of one elevator selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. The selected elevator shall be capable of carrying a gurney. The selected elevators do not need to be in the building requesting the NPC 4D Level 2 or Level 3 upgrade, but shall be accessible on the patient, surgical, obstetrical, and ground floors and be reasonably close to the building in question.

Skilled Nursing Facility (SNF)/Acute Psychiatric Facility#

1. Do Skilled Nursing Facility buildings have to meet the requirements of SB 1953?#

Skilled Nursing Facility buildings (SNFs) which are licensed under 1250 (c) of the Health and Safety Code do not have to meet the requirements of SB 1953. Also precluded are hospital buildings that are licensed under Section 1250 (a), General Acute Care, but provide skilled nursing services only. For additional information, refer to the response to Question #3 below.

2. What are the SB 1953 requirements when a Skilled Nursing Facility (SNF) is on the third floor of a General Acute Care (GAC) building?#

The entire building is subject to the SPC requirements. With respect to the NPC requirements, the SNF area would not be considered “critical care area” under the NPC 3 category for compliance, but it will be subject to the NPC 4 and NPC 4D  requirements for compliance.

3. My SNF building is under GAC license but it is a separate building on the campus. Does SB 1953 require this building to be evaluated?#

The Seismic Evaluation Procedures and Compliance Plan Regulations were developed by HCAI specifically for implementation by GAC licensed hospital buildings in furtherance of the Alfred E. Alquist of Hospital Facilities Seismic Safety Act of 1983. These regulations require GAC licensed hospitals to perform seismic evaluations on their respective facilities and for mitigation of substandard structural and nonstructural conditions by the seismic retrofit (compliance) plan.

In the 2022 California Administrative Code, Chapter 6, Section 1.2, Definitions, the term “General Acute Care Hospital” is defined. It states in part the following:

“…a hospital building as defined in Section 129725 of the Health and Safety Code and also licensed pursuant to Section 1250 (a) of the Health and Safety Code…(but) It also precludes hospital buildings that may be licensed under the above mentioned code sections, but provide skilled nursing services only.”
Therefore, a building which contains no GAC licensed beds or services but is used only for SNF beds and services is not subject to the requirements of SB 1953 even though it is under the GAC license. However, the building must be “freestanding and separate” in accordance with the conditions set forth in #HSC-129725, revised August 20, 1996. For additional information, refer to Question #4 below.

4. If all the GAC beds are moved into one building and all the SNF beds are moved into and/or remain in another building, is the building containing the SNF beds subject to the requirements of SB 1953?#

No. Even if the SNF beds are listed on the general acute care license, this building is not subject to SB 1953. It is not a hospital building within the meaning of Section 130005 (k) of the Health and Safety Code. See also 2022 California Administrative Code, Chapter 6, Part 1, Article 1, Section 1.2, Definitions – General Acute Care Hospital. This section explicitly excludes hospital buildings that provide skilled nursing services only. However, this building must be physically separate from the building housing GAC services or be separated by a seismic joint. This answer also applies to existing, separate buildings listed on the general acute care license that exclusively contain SNF beds.

Facilities should be aware of the possible Medi-Cal reimbursement consequences of a general acute care hospital providing SNF services in a separate building. Reference should be made to Health and Safety Code Sections 1250.8 and 1254 relating to separate licenses for “separate freestanding facilities” providing SNF services.

Facilities should also be aware that Department of Public Health licensing approval is required before beds or space approved for one use may be used for or converted to another use.

If a new, separate SNF license is required, facilities should consult with HCAI and the Department of Public Health licensing to discuss the means by which they will demonstrate compliance with Title 24 requirements (including structural) for SNF′s. The facility, of course, may request the utilization of alternate means and methods found in Chapter 1, Part 2, Title 24.

Facilities should also be aware of §72205 of Title 22 which requires that “The licensee shall maintain the skilled nursing facility in a safe structural condition. If the Department determines in a written report submitted to the licensee that an evaluation of the structural condition of a skilled nursing facility building is necessary, the licensee may be required to submit a report by a licensed structural engineer which shall establish a basis for elimination or correcting the structural conditions which may be hazardous to occupants. The licensee shall eliminate or correct any hazardous conditions.”

5. Are acute psychiatric (or skilled nursing) facilities exempt from seismic retrofit requirements?#

Seismic retrofit requirements apply to General Acute Care Hospital buildings (as defined in the 2022 California Administrative Code Chapter 6), therefore, buildings, including SPC and/or free-standing buildings, providing only skilled nursing or acute psychiatric services are exempt.

Conversion of General Acute Care Hospital buildings for acute psychiatric or skilled nursing uses can be complex especially if the subject building is located in a facility that also provides general acute care services in other buildings at the same site. It is recommended that a meeting with the regional supervisor of the Building Safety Section of HCAI/OSHPD be arranged to discuss all possible issues related to the conversion.

Chapter 6 of the 2022 California Administrative Code
GENERAL ACUTE CARE HOSPITAL as used in Chapter 6, Part 1 means a hospital building as defined in Section 129725 of the Health and Safety Code and that is also licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code, but does not include these buildings if the beds licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code, as of January 1, 1995, comprise 10 percent or less of the total licensed beds of the total physical plant, and does not include facilities owned or operated, or both, by the Department of Corrections. It also precludes hospital buildings that may be licensed under the above mentioned code sections, but provide skilled nursing or acute psychiatric services only.

AB 2190 Attestation#

1. What is an AB 2190 Attestation statement? #

A hospital owner or operator who has a facility with one or more buildings with a structural performance rating of less than SPC 3 or whose non-structural performance rating is less than NPC 5 must submit a statement to HCAI attesting that its board of directors is aware of that their hospital buildings are required to meet the January 1, 2030 deadline for substantial compliance.  (H&S Code Section 130066)

2. What does HCAI require to be included in the attestation?#

The attestation is a written statement that the board of directors is aware of its 2030 requirements.

3. Does the owner or operator of the facility need to disclose its compliance plan in its attestation?#

No.  H&S Code 130066 only requires an attestation of the awareness of the board of directors of its obligation to meet seismic safety deadlines.

4. When are attestations due to HCAI?#

Attestations must be received by HCAI prior to January 1, 2020.

5. What will HCAI do with the attestation statement?#

Attestations are public records due to their mandate in law.  Attestation letters will be publicly available on the Facility Detail page of the HCAI Office of Statewide Hospital Planning and Development (OSHPD) web site for each responding facility. 

6. What will happen if our facility does not submit an attestation statement?#

If a hospital does not submit an attestation, that hospital will be marked with the phrase “AB2190 Attestation Not Submitted” on the Facility Detail page.

7. Can an attestation letter be for more than one facility?#

If a healthcare system wants to submit one letter for all the hospitals for which they are the governing authority, they need to specify which hospitals and which building(s) at each hospital that are not in substantial compliance, the letter is intended to cover.  HCAI will duplicate and apply to each campus that is detailed in the letter.

AB 1882 Annual Status Reporting & Hospital Signage#

Annual Status Reporting#

1. Who must report yearly under AB 1882?#

All operational hospitals licensed as general acute hospitals or that have any general acute care category licensed beds that are subject to SB 1953 requirements. This means acute rehabilitation hospitals, surgical hospitals, etc., are subject to the reporting requirements. The owner of an acute care inpatient hospital that includes a general acute care building that is not SPC 3/NPC 5, SPC 4D/NPC 5, SPC 4/NPC 5, or SPC 5/NPC 5 shall provide an annual status update on the Structural Performance Category ratings of the buildings and the services provided in each hospital building on the hospital campus.

2. How do I do the required reporting?#

The reporting needs to submitted online through eServices Portal (eSP).  See eSP User Guide Hospital Services Reporting for instructions.

3. What documents are required for AB 1882 service reporting application?#

Please follow the eSP User Guide Hospital Services Reporting. No additional documents are required.

4. What should be reported when the facility NPC/SPC ratings have “s” letters, such as SPC 5s, NPC 4s?#

An “s” designation is a reported SPC/NPC rating to HCAI/OSHPD, not an approved rating. This “s” designation typically indicates that there is some missing documentation that is required to be provided. Please email the Seismic Compliance Unit (SCU) for instructions to clear “s” designation.

5. When filling out the services in the eSP application website, can I leave a blank for service type for a building?#

No, all buildings need at least one service selected. If the building doesn’t contain any of the acute care services, select ‘Non-GAC Uses’ and enter a brief description of the building service(s).

6. What if my facility no longer has any acute care functions, but is licensed as a General Acute Hospital?#

Contact CDPH L&C to see if the facility needs to be relicensed to reflect the current usage. Once the facility is relicensed as something other than a General Acute Care hospital, please email the Seismic Compliance Unit (SCU) a scanned copy of the paper license and the record will be updated to exempt the AB 1882 reporting requirement.

7. What if I need to add a GAC building to the inventory?#

Submit an application to the Seismic Compliance Unit (SCU) to add a building to the OSHPD building inventory. Following the creation of the new building number, AB 1882 reporting of the services for the added building is required.

8. What if I need to remove a GAC building from the inventory?#

Submit an application to the Seismic Compliance Unit (SCU) explaining why the building should be removed from the building inventory. Reasons include demolition, reclassification as an OSHPD 1R, building returned to the local authority having jurisdiction, etc. The AB 1882 services list will be updated following the removal of the building.

Hospital Signage & Posting Requirements#

1. PIN 75 states the following: “The proposed location and the content of the notice are required to be accepted by the department through a construction project submittal.” Is an Amended Construction Document (ACD) or a new project acceptable to submit for posting?#

Please submit an application with a specific record type (GACSIGN) using the eServices Portal (eSP). Please follow the eSP User Guide Hospital Signage Reporting for the step-by-step application process.

2. What documents are required for the signage application?#

Please follow the eSP User Guide Hospital Signage Reporting. A floor plan showing the signage locations and the signage page selected and filled in from PIN 75 are required to be uploaded as part of the AB 1882 signage application.

3. Is only one notice needed for each non-compliant structure?#

The law requires posting in any lobby or waiting area generally accessible to patients. The department may agree with a fewer number of posting locations depending on the floor(s) layout and use of space. Please submit an application with proposed posting locations for the department’s review and approval.

4. Can this be done as part of another ongoing project on the site?#

No. Please submit a new AB 1882 signage application using eSP.

5. There are general acute care buildings without lobby or waiting areas, would posting still be required?#

If there is no lobby or waiting area, the department will review the location of the posting on a case-by-case basis. AB 1882 posting is not required for equipment yards, tunnels, canopies, cooling towers, or emergency generator enclosures.

6. Are these signs expected to be printed pieces of paper? What about signage to wall connection detail?#

There is no required material type for the signage. The signage should be protected from damage and securely adhered or hung on the wall.

7. Is it sufficient to provide a general location, such as pointing to the approximate area on a floor plan, or does the exact location need to specified?#

Pointing to the approximate area on a floor plan is acceptable. The installed signage is required to be verified and accepted by HCAI field staff.

8. Will the HCAI regions be reviewing these AB 1882 projects, or will they go through the Seismic Compliance Unit (SCU)?#

Review and approval will be done by the corresponding region or field staff.

9. Do we need to complete project kick-offs with the field staff? District Structural Engineer (DSE), Fire Life Safety Officer (FLSO), and Compliance Officer (CO)?#

No.

10. Do we need an Inspector of Record (IOR), Testing Inspection Observation Program (TIO), or Verified Compliance Report (VCR) by the Design Professional of Record (DPOR)?#

No.

11. Can the sign be moved at a later date?#

For revised location, please submit a new AB 1882 signage application using eSP.

12. Is a version of the sign for the visually impaired required?#

Braille signage is not required.

13. If the building SPC or NPC rating changes, would revised signage be required?#

Yes.

14. Can the facility provide supplemental information to the posting?#

No supplemental information on the posting will be allowed. However, additional informational postings around the signage that does not interfere with the AB 1882 signage posting is allowed.

15. The statement says no deviation from the notice format. Assuming that the format remains as is, can the statement be adjusted?#

The statement, the size, or the format cannot be revised.

16. Is the signage requirement in Section 130065 applicable only to the first floor, or does it apply to all floors including the basement in multi-story buildings?#

The signage requirement in Section 130065 applies to all floors in multi-story buildings, including the basement. This is because the section states that signs must be posted in “any lobby or waiting area generally accessible to patients or the public.” Therefore, all floor plans, including the basement, must be submitted with the locations of posted signage clearly marked. In the absence of lobby or waiting room place the signage in front of elevator/stair exit or in corridor. A minimum of one signage per floor is required.

17. Is signage required for a building that is not open to the public or does not see patients or provides no general acute care services?#

Yes, provide at least one signage for OSHPD 1 building at each floor.

18. Is signage required for OSHPD 1R or OSHPD 2 or OSHPD 5 buildings?#

Signage is not required for OSHPD 1R or OSHPD 2 or OSHPD 5 buildings.